Advancing Quality (AQ)

More patients are admitted to hospital as a result of pneumonia in the north of England compared to the south. In the North West in 2019, the rate per 10,000 population was 58.5. To help reduce unwarranted clinical variation and health inequality, capture best practice and share evidence-based insights to AQ members across the North West, the AQ team created ‘Insight Reports’.

The Advancing Quality Alliance (Aqua) developed a collaborative approach to support organisations to improve their early recognition of the deteriorating patient. The programme combined theory, practical application and group discussions to support learning. The programme was delivered across three days over nine months; coaching teams in the application and delivery of Quality Improvement (QI) approaches to improve the early detection of deteriorating patients. Teams identified a particular aspect of deterioration they wished to explore worked and learned together. Each participating team developed a core skill set to understand and influence behaviours and approaches applicable in daily practices to support improvements.

Southport and Ormskirk Hospitals NHS Trust has established a steering group to improve care for patients with AKI. The group is using the care bundle data from the Advancing Quality Alliance (AQuA) Advancing Quality (AQ) AKI programme to monitor care delivery for patients with AKI and to provide a framework for improvement.

Acute Kidney Injury is a sudden and recent reduction in a person’s kidney function. It is estimated that approximately 100,000 deaths are associated with AKI each year with up to 30% of these being preventable with the correct care and treatment. NCEPOD (2009). Aintree University Hospital NHS Foundation Trust has directed its attention to improving the care delivery of patients who develop AKI for approximately five years. The STOP-AKI project was triggered following a mortality analysis at the trust and joint collaboration with the Institute of Healthcare Improvement, Boston, USA.

The Covid-19 pandemic meant that it was not business as usual for the Advancing Quality (AQ) programme in 2020. The programme responded to the challenges of Covid by diversifying and finding new ways to connect with and support trusts across the North West of England. Highlights include two new Clinical Focus Areas, a shift to virtual delivery, a new series of collaborative events, expanded reporting and national media coverage for our pneumonia programme.

A fundamental part of the Advancing Quality (AQ) programme is to provide tailored improvement coaching for participating organisations and to bring them together to share learning. As 2020 brought unprecedented challenges from the Covid pandemic, the AQ programme adapted to find new ways to work collaboratively with care providers, embracing the opportunities provided by virtual technology in line with the principles outlined in our four improvement pillars.

Aintree University Hospital NHS Foundation Trust joined the Advancing Quality (AQ) programme at its launch in 2008 and is currently participating in eight clinical focus areas (CFA), this includes Alcohol Related Liver Disease (ARLD).

NHS England defines frailty as ‘where someone is less able to cope with and recover from accidents, physical illness or other stressful events’1. As the population ages, so frailty rates increase, presenting challenges to care systems. Elective hip and knee replacement patients undergo pre-surgical checks to ensure they are able to cope with their procedure.

Sepsis and deterioration is a huge clinical problem and 70% of sepsis cases originate in Primary Care. In the last five years we have experienced a culture shift in primary care; from seeing sepsis as an acute condition that is difficult to detect, to recognising the need to actively assess patients where infection could be causing significant illness or deterioration.

The Royal College of Surgeons1 describes a “mountain-sized” backlog of cancelled elective procedures caused by Covid-19 which will require “a five year plan to address” Quoted in Brennan (2020). The CovidSurg Collaborative (2020) estimates half a million cancellations between April and June 2020 in the UK. SUS (2020). Ibid. NHS Digital (2020). AQ (2020).

Sepsis is a life-threatening condition which has in recent years become a high priority for healthcare providers. Early recognition and prompt management of sepsis can improve outcomes for patients, reducing the risk of mortality and morbidity. This could potentially save 14,000 lives and result in 400,000 fewer days in hospital for patients every year, according to estimates by the Sepsis Trust.

Southport and Ormskirk Hospital NHS Trust provides acute hospital services to 258,000 people across Southport, Formby and West Lancashire. Acute care is provided at Southport and Formby District General Hospital and Ormskirk and District General Hospital. Sepsis accounts for around 1,200 acute admissions to the trust each year.

Advancing Quality (AQ) is a North West programme designed to identify and reduce unwarranted variation in the delivery of care across healthcare organisations. Driven by the needs of the participating organisations, the programme offers members a structured approach to embedding evidence based care, enabling the highest quality care to be provided to every patient, every time. The AQ Sepsis programme relies on organisational commitment, executive support, clinical leadership and engagement from front line staff to deliver a collective approach to improving patient outcomes.

Evidence suggests that implementing an effective and sustainable program to address severe sepsis requires a dedicated team. St Helens and Knowsley Teaching Hospitals (StHK) established a team of sepsis nurse specialists to deliver a 24 hour service to identify diagnose and treat patients with sepsis. The team focus on clinical care provision in ED, learning from case reviews and educating staff across the trust. The introduction of a specialist team has supported the work of the trust to increase the proportions of patients being screened for sepsis, the timely treatment of patients and reduced hospital mortality and the readmission rate for people with sepsis.

The 2009 NCEPOD report, Adding Insult to Injury, reviewed outcomes for patients with acute kidney injury (AKI) in hospital. The report found that medication was the most common AKI risk factor not assessed and only 15% of patients had their medication altered to renal doses. The national AKI programme Think Kidneys advises that medicines optimisation is essential to reduce the risk of AKI and mitigate its severity if it occurs.

Recognising there was considerable variation in performance for the AQ sepsis measure set across Pennine hospital sites, the trust wanted to improve consistency in diagnosis and treatment of patients presenting with suspected sepsis. The National recommendation to transition to using the NEWS2 assessment criteria gave the organisation the opportunity to review current practice to ensure early recognition and escalation of the deteriorating patient was paramount in admission areas.

Acute kidney injury (AKI) may sometimes be caused by an obstruction in the urinary tract, which can require treatment with a nephrostomy. It is important that people with AKI who are suspected of having a urinary obstruction receive an ultrasound scan early in their management, as outlined in national guidance (NICE, 2019).

Mid Cheshire Hospitals NHS Foundation Trust (MCHFT) wanted to improve recognition of sepsis across the organisation, ensuring that early recognition and treatment promoted optimal outcomes and experience for patients. MCHFT is an acute hospital trust with three sites across Cheshire: Leighton Hospital, Victoria Infirmary, and Elmhurst Intermediate Care Centre.

In patients who are, or become acutely unwell in hospital, there is evidence that deterioration is not always recognised or it is not acted on rapidly enough (NICE, 2007). The Walton Centre NHS Foundation Trust wanted to improve observation recording, recognition and response to deteriorating patients using the NEWS assessment tool.

The NICE (2014) guidance publication ‘Pneumonia in Adult: Diagnosis & Management’ covers diagnosing and managing Community Acquired Pneumonia (CAP) in adults. Its aim is to improve the accurate assessment and diagnosis of pneumonia to help guide antibiotic prescription and ensure that people receive the right care. It estimates a mortality rate between 5% and 14% for patients admitted to hospital with CAP.

More than seven out of ten people with sepsis develop the condition outside of hospital (Esteban, 2007); any strategy to identify sepsis cases early should consider the delivery of timely care in the community. Pennine Acute Trust Community Services have developed a mechanism for early identification of sepsis in the community setting.

In 2015, an All Parliamentary Group was established which called for the need to address sepsis across the NHS and NHS England identified tackling sepsis as a clinical priority for improving patient outcomes. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) highlighted lessons learnt from sepsis cases and provided key recommendations for improving the quality and safety of care. Of these 21 recommendations, 6 were identified as being relevant to the care homes within Lancashire County Council.

he Royal Liverpool & Broadgreen University Hospitals NHS Trust (RLBUHT) identified an opportunity to improve the early diagnosis of patients with sepsis. Evidence suggests that the sickest sepsis patients have high levels of serum lactate. Timely measurement of serum lactate levels in patient pathways can improve early diagnosis which will lead to improved outcomes.